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Pulmonary arterial hypertension is a severe and progressive disease characterized by a pulmonary vascular remodeling process with expansion of collateral endothelial cells and total vessel occlusion. Endothelial cells are believed to be at the forefront of the disease process. Vascular endothelial growth factor (VEGF) and its tyrosine kinase receptor, VEGF receptor-2 (VEGFR-2), play a central role in angiogenesis, endothelial cell protection, but also in the destabilization of endothelial barrier function. Therefore, we investigated the consequences of altered VEGF signaling in an experimental model, and looked for translational correlates of this observation in patients. We performed an endothelial cell-specific conditional deletion of the  kinase insert domain protein receptor  ( kdr ) gene, coding for VEGFR-2, in C57/BL6 mice ( Kdr   ∆end   )  and held them in an environmental chamber with 10% FiO 2  or under normoxia for 6 weeks.  Kdr  knockout led to a mild PH phenotype under normoxia that worsened under hypoxia.  Kdr   ∆end   mice exhibited a significant increase in pulmonary arterial wall thickness, muscularization, and VEGFR-3 +  endothelial cells obliterating the pulmonary artery vessel lumen. We observed the same proliferative vasculopathy in our rodent model as seen in patients receiving anti-angiogenic therapy. Serum VEGF-a levels were elevated both in the experimental model and in humans receiving bevacizumab. Interrupted VEGF signaling leads to a pulmonary proliferative arteriopathy in rodents after direct ablative gene manipulation of  Kdr.  Histologically, similar vascular lesions can be observed in patients receiving anti-VEGF treatment. Our findings illustrate the importance of VEGF signaling for maintenance of pulmonary vascular patency.   Electronic supplementary material  The online version of this article (10.1007/s00395-020-0811-5) contains supplementary material, which is available to authorized users.

Interruption of vascular endothelial growth factor receptor 2 signaling induces a proliferative pulmonary vasculopathy and pulmonary hypertension